Documenting Respiratory, Cardiovascular and Neurological Systems

General observations made during the initial assessment of a patient include their appearance, mobility, ability to communicate, and cognitive function.  Use this table to evaluate your general assessment skills and how you record your findings. If you identify areas you are shallow in, and then make the appropriate adjustments the next time you record patient care.  

Guidelines for General Observations
Respiratory system
After examining the respiratory system, document the following:
Assessed	Rate and rhythm or respirations
Auscultated	The lung fields
Inspected	Sputum for color, consistency and other characteristics.
Cardiovascular system
After examining the cardiovascular system, document the following:
Auscultated	For heart sounds
Assessed	Heart rate and rhythm
Assessed	The color and temperature of the extremities
Assessed	The peripheral pulses; record the quality by “number”
Inspected	For edema (pitting; record by “number”)
Inspected	The neck veins (distention)
Neurological system
After examining the neurological system, document the following:
Inspected	The patient’s head for evidence of trauma
Assessed	The patient’s level of consciousness, including orientation to time, place, person and situation
Assessed	The patient’s ability to follow commands
Assessed	The patient’s pupillary reactions and cranial nerve function
Assessed	The patient’s extremities for movement and sensation

Top 5 Malpractice Claims Made Against Nursing Professionals

Chances are at some point in your career, you will either:

• Have a claim made against your professional services.
• You will be named in a group lawsuit - whether as part of a larger group of health care professionals and/or included with your health care facility.
• Witness a negligent act by another health care professional during the course of a normal work day.
• Be deposed to testify on behalf of yourself, your employer or colleague. 

No matter what the situation, being involved in any allegation of malpractice can be emotionally and financially devastating for all parties.   However, if you are specifically named in the malpractice suit, your asset, reputation and career could all be in jeopardy.  It is important to understand the most common allegations and how they happen in order to minimize your risk.  Most malpractice calms involve at least one of the following allegations:

1. Failure to follow standards of care
2. Failure to use equipment responsibly
3. Failure to document
4. Failure to assess and monitor the patient
5. Failure to communicate.

I will discuss these five common allegations in the coming blog posts, so stay in touch!

Documenting GU, Skin and Reproductive Systems

General observations made during the initial assessment of a patient include their appearance, mobility, ability to communicate, and cognitive function.  Use this table to evaluate your general assessment skills and how you record your findings. If you identify areas you are shallow in, and then make the appropriate adjustments the next time you record patient care. 

Guidelines for General Observations
Genitourinary system
After examining the genitourinary system, document the following:
Assessed	For bladder distention or incontinence
Inspected	The genitalia for rashes, edema, or deformity, if indicated.  (inspection can be waived as appropriate)
Integumentary system
After examining the integumentary system, document the following:
Inspected	The patient for sores, lesions, scars, pressure ulcers, rashes, bruises, or petechiae.  Record on the skin assessment form upon admission.
Assessed	The patient’s skin turgor.
Reproductive system
After examining the reproductive system, document the following:
Inspected	The genitalia for sexual maturity and abnormal discharge, if indicated
Performed	A breast examination, if permitted, and whether you found abnormalities

Top 5 Malpractice Claims Made Against Nursing Professionals

Chances are at some point in your career, you will either:

• Have a claim made against your professional services.
• You will be named in a group lawsuit - whether as part of a larger group of health care professionals and/or included with your health care facility.
• Witness a negligent act by another health care professional during the course of a normal work day.
• Be deposed to testify on behalf of yourself, your employer or colleague. 

No matter what the situation, being involved in any allegation of malpractice can be emotionally and financially devastating for all parties.   However, if you are specifically named in the malpractice suit, your asset, reputation and career could all be in jeopardy.  It is important to understand the most common allegations and how they happen in order to minimize your risk.  Most malpractice calms involve at least one of the following allegations:

1. Failure to follow standards of care
2. Failure to use equipment responsibly
3. Failure to document
4. Failure to assess and monitor the patient
5. Failure to communicate.

I will discuss these five common allegations in the coming blog posts, so stay in touch!

Documenting EENT, GI, and Musculoskeletal Systems

General observations made during the initial assessment of a patient include their appearance, mobility, ability to communicate, and cognitive function.  Use this table to evaluate your general assessment skills and how you record your findings. If you identify areas you are shallow in, and then make the appropriate adjustments the next time you record patient care. 

Guidelines for General Observations
Eyes, ears, nose, and throat
After examining the eyes, ears, nose, and throat, document the following:
Assessed	The patient’s ability to see objects with or without corrective lenses as appropriate
Assessed	The patient’s ability to hear spoken words clearly
Inspected	The patient’s eyes and ears for discharge; the nasal mucous membranes for dryness, irritation, and the presence of blood; and teeth for cleanliness
Assessed	How well the patient’s dentures fit, if appropriate
Assessed	The condition of the oral mucous membranes
Palpated	The lymph nodes in the neck
Gastrointestinal system
After examining the gastrointestinal system, document the following:
Auscultated	For bowel sounds in all quadrants
Assessed	For abdominal distention or ascites
Palpated	The abdomen to assess for tenderness
Musculoskeletal system
After examining the musculoskeletal system, document the following:
Assessed	The range of motion of major joints
Assessed	For swelling at the joints
Assessed	For the presence of contractures, muscular atrophy, or deformities

Top 5 Malpractice Claims Made Against Nursing Professionals

Chances are at some point in your career, you will either:

• Have a claim made against your professional services.
• You will be named in a group lawsuit - whether as part of a larger group of health care professionals and/or included with your health care facility.
• Witness a negligent act by another health care professional during the course of a normal work day.
• Be deposed to testify on behalf of yourself, your employer or colleague. 

No matter what the situation, being involved in any allegation of malpractice can be emotionally and financially devastating for all parties.   However, if you are specifically named in the malpractice suit, your asset, reputation and career could all be in jeopardy.  It is important to understand the most common allegations and how they happen in order to minimize your risk.  Most malpractice calms involve at least one of the following allegations:

1. Failure to follow standards of care
2. Failure to use equipment responsibly
3. Failure to document
4. Failure to assess and monitor the patient
5. Failure to communicate.

I will discuss these five common allegations in the coming blog posts, so stay in touch!

Documenting Communication and Cognitive Function

General observations made during the initial assessment of a patient include their appearance, mobility, ability to communicate, and cognitive function.  Use this table to evaluate your general assessment skills and how you record your findings. If you identify areas you are shallow in, and then make the appropriate adjustments the next time you record patient care. 

Guidelines for General Observations
Communication
Speech	Speaks clearly in English (or other spoken language)
	Speaks with only one word responses; does not respond to verbal stimuli
	Speech is slurred, hearse, loud, soft, incoherent, hesitant, slow, fast, or nonsensical
	Has difficulty completing sentences due to shortness of breath or pain.
Hearing	Hears well enough to respond to questions
	Hard of hearing; wears hearing aid; must speak loudly into left or right ear.
	Deaf; reads lips or uses sign language
Vision	Sees well enough to read instructions in English or other language
	Wears corrective lenses to see or to read
	Cannot read.
	Blind (one eye or both)
Cognitive functions
Awareness	Oriented x 3 and aware of surroundings and situation
	Disoriented; unaware of time, place, person, or situation
Mood	Responds appropriately; talkative
	Answers in one-word responses; offers information only when asked direct questions
	Hesitates in answering questions; looks to family or support person before answering
	Angry; states “Leave me alone” (use quotations to record what they say); speaks loudly and abruptly to family or support person(s).
	Maintains or avoids eye contact
Thought processes	Maintains a conversation; makes relevant statements; follows commands appropriately
	Mind wanders; makes irrelevant statements; follows commands inappropriately.

Top 5 Malpractice Claims Made Against Nursing Professionals

Chances are at some point in your career, you will either:

• Have a claim made against your professional services.
• You will be named in a group lawsuit - whether as part of a larger group of health care professionals and/or included with your health care facility.
• Witness a negligent act by another health care professional during the course of a normal work day.
• Be deposed to testify on behalf of yourself, your employer or colleague. 

No matter what the situation, being involved in any allegation of malpractice can be emotionally and financially devastating for all parties.   However, if you are specifically named in the malpractice suit, your asset, reputation and career could all be in jeopardy.  It is important to understand the most common allegations and how they happen in order to minimize your risk.  Most malpractice calms involve at least one of the following allegations:

1. Failure to follow standards of care
2. Failure to use equipment responsibly
3. Failure to document
4. Failure to assess and monitor the patient
5. Failure to communicate.

I will discuss these five common allegations in the coming blog posts, so stay in touch!